Basic Information
| Provider Information | |||||||||
| NPI: | 1033313200 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HARBOR HOSPICE OF OAKDALE, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3406 COLLEGE ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | BEAUMONT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 777014612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4098132332 | ||||||||
| FaxNumber: | 4092320573 | ||||||||
| Practice Location | |||||||||
| Address1: | 209 N 16TH ST | ||||||||
| Address2: | |||||||||
| City: | OAKDALE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 714632211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3183355029 | ||||||||
| FaxNumber: | 3183355066 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2007 | ||||||||
| LastUpdateDate: | 01/27/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | THIBODAUX | ||||||||
| AuthorizedOfficialFirstName: | BRAD | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF DATA OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 4098132332 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X | PENDING | N | Agencies | Hospice Care, Community Based | 251G00000X | 19-1656 | LA | Y | Agencies | Hospice Care, Community Based |
ID Information
| ID | Type | State | Issuer | Description | 268 | 01 | LA | DHH | OTHER | 1031810 | 05 | LA | MEDICAID |